This was a cross-sectional study conducted among 360 antenatal women visiting the Outpatient Department (OPD) and wards of Obstetrics and Gynaecology at Indira Gandhi Medical College Hospital and Research Institute, a tertiary care teaching hospital in Pondicherry, India from April 2023 to June 2023. Institute Research Committee (IRC) and Institutional Ethics Committee (IEC) approval (NO. 455/IEC-37/IGMC&RI/PP-6/2023) were obtained for conducting the study. Written informed consent was obtained from all the eligible participants before data collecting, and strict confidentiality was maintained throughout the study.

Inclusion criteria: Antenatal women who were attending OBG-OPD and in wards at the time of data collection and who gave consent were included in the study.

Exclusion criteria: Non-pregnant women attending OPD, antenatal women who did not show enough willingness and interest to participate in the study were excluded from the study.

Sample size: The sample size was calculated based on the study done by Bhilwar M et al., [12]. Considering that 37.13% of the beneficiaries are aware of BPACR, with an absolute precision of 5%, at 95% confidence intervals and 80% power, sample size was calculated as 359. The study respondents were selected using a systematic random sampling method, where every 3^rd client was chosen until the required sample size was obtained.

The selected antenatal mothers were approached and explained about the study. A structured interview was used to collect the necessary data, which comprised three parts:

Part 1: Socio-demographic details, included age, religion, type of family, number of family members, education of the participant and occupation of participant. Socio-economic status was calculated using the BG Prasad Scale [13].

Part 2: Obstetric characteristics, such as gravidity, parity, abortions, antenatal follow-up and presence of any complications.

Part 3: Awareness about danger signs and birth preparedness.

BPACR steps include [8]- Arranging a mode of transport, saving money for pregnancy and childbirth, identifying an institution for delivery, and arranging a blood donor. Based on the number of practices followed, the they are grouped as follows:

The knowledge of antenatal women about the danger signs of illness during pregnancy and childbirth were documented. Among the participants, those who identified ≥3 danger signs were considered to have good knowledge of the antenatal and childbirth danger signs, while the rest of the participants who identified <3 were considered to have poor knowledge [7].

The 10 components based on indicators mentioned by JHPIEGO are as follows:

With the help of the above components of BPACR, the BPACR indices were calculated as percentages for a total of 360 participants [8].

Statistical analysis was performed using MS Office Excel and Statistical Package for the Social Sciences (SPSS) software version 21.0. The data were analysed using descriptive statistics. The Chi-square test was used to demonstrate the difference between study subject characteristics, and level of significance was set at p≤0.05.

The mean age of the participants was 25.25±4.9 years, ranging from 17 to 40 years. Around 231 (64.2%) women were in the 21-30 years age group. Of all the respondents, 6 (1.7%) were in first trimester, 21 (5.8%) in second trimester, and 333 (92.5%) in third trimester, as described in [Table/Fig-1].

Awareness about danger signs of pregnancy: The respondents were asked to identify the danger signs during pregnancy. About 22 (6.1%) participants did not identify any danger sign, while 179 (49.7%) were able to identify at least one danger sign. While 110 (30.5%) participants identified two danger signs, 42 (11.7%) participants identified three danger signs, and only seven (2.0%) participants identified >3 danger signs. Hence total of 49 (13.6%) participants had good knowledge about antenatal danger signs. Excessive bleeding per vagina (84.7%) was the most commonly identified antenatal danger sign, followed by severe abdominal pain (29.7%) [Table/Fig-2]. The knowledge of antenatal danger signs showed a significant association with educational status (p-value=0.023) and number of ANC visits (p-value=0.046) [Table/Fig-3].

Awareness about danger signs during childbirth: About 137 (38.1%) participants did not identify any danger signs during childbirth. Meanwhile, 176 (48.9%) and 28 (7.8%) participants were able to identify one and two danger signs, respectively. While 19 (5.3%) participants had good knowledge of danger signs during childbirth, i.e., identified ≥3 danger signs. After analysis with all the socio-demographic factors, educated, working women participants had good knowledge of danger signs of childbirth [Table/Fig-3], with significance levels of p-value <0.001, p-value=0.014, respectively. Severe bleeding per vagina (60.3%) was the most commonly identified danger sign of childbirth [Table/Fig-4].

BPACR attitude and practice: Only 64 (17.8%) participants had heard about BPACR. The majority of the women 241 (66.9%) saved money for their delivery. Thirty women (8.3%) identified a skilled provider for delivery, and 50 (13.9%) identified either personal or government modes of transport to reach a health facility during delivery, as shown in [Table/Fig-5].

A total of 51 (14.2%) participants were well prepared for their birth, while the rest, 215 (59.7%), were less prepared, and 94 (26.1%) women were totally unprepared. In the analysis [Table/Fig-6], a significant association of BPACR with level of education (p-value <0.001) and occupation (p-value=0.024) was found. The various indicators used to evaluate the preparedness level of individuals for delivery and its complications are calculated and given in [Table/Fig-7].

BPACR is a matrix of shared responsibility of expecting mother, her family, and the community. It is an essential tool to ensure safe motherhood by improving the health-seeking behaviour and individual preparedness for emergencies during pregnancy and childbirth. The mean age of the respondents was 25.25±4.9 years, which was very close to 25.2±4 years in a study by Kamineni V et al., [14]. The majority of the participants were aged between 21-25 years (31.4%), and half of the study participants (59.2%) had completed secondary-level education, which was comparable to a study conducted by Patil AA et al., in Shivamoga district of Karnataka, where 37.2% of women were between 20-24 years and 58% had completed secondary-level education [15]. This finding reflects a good promotion of education for all by various government programs.

The current study found that 13.6% and 5.3% of women had good knowledge of danger signs during antenatal care and childbirth, respectively. This was low compared to studies like Bhilwar M et al., which showed 27.8% and 6.7%, and Karir DS et al., which showed 30.6% and 10.8% for danger signs during antenatal care and childbirth [12,16]. This low awareness could be due to less age at first pregnancy and less number of ANC visits. The involvement of family, peers, mass media, and effective communication by health providers to propagate the danger signs could be of utmost importance in improving awareness, thereby helping pregnant women identify obstetric emergencies and seek medical care as early as possible.

Of the BPCR practices, only 14.2% were found to be well prepared, which was less compared to the study by Patil AA et al., showing 38% [15]. The most commonly followed practice in the present study was saving money, followed by identifying modes of transport, while the least common practice was identifying a matched blood donor. The percentage of women who saved money was observed by other studies was 58% by Bhilwar M et al., 44% by Patil AA et al., and 50% by Sulekha T et al., [12,15,17]. The awareness about blood donor in other studies were 7.5% according to Bhilwar M et al., 4% in Patil AA et al., and (11%), the highest, reported by Kamineni V et al., [12,14,15].

The BPCR indices were evaluated at the individual level. The overall BPCR index was calculated as 51.76%. A Chi-square test examining the association between BPCR and socio-demographic factors found a significant association with education level and occupation, with p-values <0.001 and 0.024, respectively. Similarly, a positive association with good education and occupation was found in studies conducted by Bhilwar M et al., Patil AA et al., and Sulekha T et al., [12,15,17]. The knowledge related to pregnancy is gained through experience, which is supported by the finding of good knowledge among women with high gravidity scores.

The study was a cross-sectional study; therefore, authors were not able to follow-up the delivery outcome of the patients based on their performance in BPACR.

The study revealed that a very small portion of the participants had good knowledge of antenatal and childbirth danger signs. BPCR was very low among the participants. Hence, more effort needs to be employed to educate women and motivate them about the importance of regular ANC visits and to create awareness about the complications. Thus this will lead to a reduction of maternal mortality and morbidity.